1. Joints (arthritis) – Rheumatoid arthritis Inflammatory dz affecting synovial joints predominately Hyperplasia of synovial fibroblasts Severity is varied Peak age is 30-50 About 1% of the population is affected with a 2.5xs higher risk in women. May be genetic as it tends to run in families More common in Native Americans

2. Insidious over several weeks usu. Usu. Not symmetric at the beginning Must have an inflammatory synovitis If deformity is in a non-wt bearing jnt, you can assume it’s due to synovitis 85% have serum RF May start sero-(-) but become sero(+) w/ progression ESR is typically helpful to follow the inflammatory activity

3. Prolonged morning stiffness is universal Active phase: warm, swollen jnts Structural damage Bone on bone crepitus Try injected corticosteroids for anti-inflammation C/s – neck stiffness w/ possible loss of motion C1 transverse lig tenosynovitis and possible z-jnt synovitis Pain doesn’t always accompany instability even in significant myelopathy

17. Immobilization due to pain is the kiss of death to joint mobilizations. The result is contractures and deformity You need to keep pt’s ROM esp. in non-wt bearing jnts like shoulder and hand Once cartilage is completely gone, bones may fuse if immobilized10% remit usu in first two yrs of dz 90% of jnts that are affected are involved during the 1 st yr Severe dz= 10-15yr decr in life expectancy due to infection, pulmonary or renal dz, lymphoproliferative disorders, GI bleeds and cardiovascular

18. RA criteria below: Morning stiffness 3+jnts Arthritis of hand Symmetric arthritis Rheumatoid nodules RF X-ray changes Need 4 of the 7 1-4 must occur for at least 6 wks

19. Stage I Early – no destruction Stage II Moderate – no jnt deformity, osteoporosis w/ or w/out some bone and cartilage destruction Stage III Severe – cartilage and bone destruction with osteoporosis, jnt deformity Stage IV Terminal – fibrous or bony ankylosis

20. Remission criteria 5+ of the following for 2+ consecutive mos. Morning stiffness</=15minutes No fatigue No jnt pain No tenderness No swelling ESR

21. GOUT Monosodium urate deposition - hyperuricemia Tophi – accumulation of crystal in articular, osseous, ST, and cartilage Recurrent attacks of inflammation Uric acid calculi in GU; renal fxn impairment called gouty nephropathy M/c 5 th decade men African-Americans –Serum urate levels rise over time in men but don’t in women until after menopause due to estrogen Gout in women is often due to thiazide diuretic use and renal failure –Blacks due to more HTN, not genetic

22. Crystals have decr solubility in low temps that’s why it likes toes and ears Likes areas of minor trauma like 1 st MTP Hemiplegia – tophi won’t form on paralyzed side -> something to do w/ CT structure and turnover Tophi is inflammatory cells around crystal w/ erosion of surrounding cartilage and bone. Fibrous capsule around tophi –Crystals are needle-shaped and formed radially

23. Three stages: asymptomatic hyperuricemia, acute intermittent gout, Chronic tophaceous gout. Initially rubor, tubor, dolor and pain of jnt. Pain incr. Over hours. Pt. May not be able to walk. May get fever, chills, malaise. May last up to 2 weeks. Attacks become more frequent w/ time –½ involve 1 st MTP as monoarticular site and 90% of pts overall

25. CHRONIC TOPHACEOUS GOUT About 10yrs after initial dx usu. No pain free period but not as severe as acute Factors for tophi development: early onset, long active phases, 4+attacks/yr, UE or polyarticular episodes Tophi can also be in heart valves and sclera Supcutaneous gouty tophy are usu in fingers “heberden’s nodes”

26. Early onset gout –<25yoa, 3-6% of gout pts, 80% have FHx –More severe and rapid course, 25% have nephrolithiasis Transplant gout –75-80% of heart transplants –Due to cycloporine tx to prevent rejection Inhibits urate excretion

29. 10% die of renal failure; 25% have renal stones 25-50% have HTN ->due to reduced renal blood flow from urate Hyperlipidemia/obesity – contraversial Xray – ST swelling -> asymmetric in peripheral jnts erosions slightly removed from jnt (unique) (“overhanging edge”) –No osteopenia, and maintained jnt space until late

30. Osteoarthritis

32. OA – Garrod in 1907 differentiated RA from OA10% of OA patients had reduced work hours and 13.7% retired early. Arthritis is the main reason for decr. Activities in the elderly